Transcript Session 4: Behavioral Problems and Substance Abuse

Managing Behavioral
Problems and
Substance Use
Mental Health Learning Collaborative Learning Session
April 10, 2015
Speakers:
Bhavin Dave, MD, Children’s National Health System
Katherine Hobbs Knutson, MD, MPH Children’s National Health System
Nicole Martino, LICSW, DC Department of Behavioral Health
Accreditation
Accreditation
The George Washington University School of Medicine and Health Sciences
is accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians.
The George Washington University School of Medicine and Health Sciences
designates this live activity for a maximum of 1.0 AMA PRA Category 1
Credit(s)™. Physicians should claim only the credit commensurate with the
extent of their participation in the activity.
Instructions for Obtaining Credit
At the end of this webinar, you will receive an email for completing the
online course evaluation. Your certificate of credit will be available
immediately after you complete the evaluation.
Disclosure
In accordance with the Accreditation Council for Continuing Medical
Education's Standards for Commercial Support, The George Washington
University Office of Continuing Education in the Health Professions (CEHP)
requires that all individuals involved in the development and presentation of
CME activity content disclose any relevant financial relationships with
commercial interest(s). CEHP identifies and resolves all conflicts of interest
prior to an individual’s participation in an educational activity.
The following faculty, planners, and staff report that they have no relevant
financial relationships with commercial interest(s):
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Bhavin Dave (Speaker)
Katherine Hobbs Knutson (Speaker)
Nicole Martino (Speaker)
Mark Weissman, MD (Course Director)
Tamara John, MPH (Staff Planner)
Leticia Hall-Salam (Staff)
Commercial Support: This activity received no support from a
commercial interest.
General Information
Release Date: March 25, 2014
Termination Date:
March 25, 2014
Hardware/Software Requirements
PC
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Contact Information
Tamara John
Ph: (202)476-5781
Em: [email protected]
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Managing Behavior Problems in
Youth
Bhavin Dave, MD
Assistant ProfessorDepartment of Psychiatry and
Behavioral Sciences
Associate Director-Infant &
Toddler Mental Health
Program
Children’s National Health
System
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Assess
• Evaluate for any mental health diagnoses
• Rule out any medical issues
• Assess for any psychosocial stressors
– At home?
– At school?
Managing Behaviors
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Treat underlying psychiatric disorders
Treat any comorbid medical issues
Address any psychosocial stressors
Identify target behaviors
Managing Behaviors
• List target behaviors
• Develop behavior intervention plan
• Recruit support services to reinforce behavior plan
Identify Target Behaviors
• Target behaviors may differ depending on age range
• List behaviors most  least impactful
• Type of intervention may depend on type and scope
of behavior
– Low acuity (oppositional, defiant, limit testing,
noncompliant, mild aggression)
– Moderate acuity (moderate aggression, bullying,
destruction of property, truancy, running away)
– High acuity (urgent/emergent behavior, i.e. threats of
harm to self or others)
Basic Principles
• Pick and choose battles!
– Some behaviors may require effective ignoring
• Be consistent, persistent (as best as possible)
• Behaviors may get worse before they get better
• Identify any parent/caregiver behaviors that
inadvertently reinforce negative behavior
• Praise/positive reinforcement is more effective than
consequence/punishment
• Involve the child as much as possible
Low Acuity Behaviors
• Develop behavior intervention plan
– Identify and teach rules
– Determine consequences
– Determine praise/rewards
• Who is involved?
– Parents
– School
– Therapist (behavior, play, individual, family)
Moderate Acuity
• Develop behavior intervention plan
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Prevention—teaching coping skills
Safe de-escalation techniques
Anti-bullying interventions in school
Create non-aggressive environment
External source of consequences (ie PINS program)
MST (Multi-systemic therapy)
• Who is involved?
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Parents
School
Therapist (in-home, behavioral, CBI worker, individual, family)
DJS
High Acuity Behaviors
• Develop intervention plan
– Maintain safety
– Crisis evaluation
– Safe transport to appropriate placement
• Who is involved?
– Crisis intervention services (911, ChAMPS: 202-481-1440)
– Inpatient unit
– DJS
Resources for Parents
• "The Kazdin Method for Parenting the Defiant Child."—Allen
E. Kazdin, PhD
• “Your Defiant Child”—Russell Barkley, PhD
• “SOS Help for Parents”—Lynn Clark, PhD
• “1-2-3, Magic”—Dr. Thomas Phelan
• “The Whole Brain Child”—Daniel Segal
• “No More Meltdowns”—Jed Baker
Substance Abuse Screening &
Brief Intervention
Katherine Hobbs Knutson,
MD, MPH
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Substance abuse screening
For adolescents, in addition to the SDQ screening (and
suicide screening), DBH and the DC Collaborative
recommend practices to additionally screen for
substance abuse with the CRAFFT tool.
CRAFFT screening tool, Children’s Hospital Boston, 2009.
CRAFFT screening tool, Children’s Hospital Boston, 2009.
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
Available at: http://www.integration.samhsa.gov/clinical-practice/sbirt/Guide_for_Youth_Screening_and_Brief_Intervention.pdf
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
Negative CRAFFT screen
Negative CRAFFT screen: provide positive
reinforcement for abstinence, consider exploring the
choice for abstinence with the patient.
Positive CRAFFT screen
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
CRAFFT screening tool, Children’s Hospital Boston, 2009.
Positive CRAFFT screen
• “No” to all questions in part A + “Yes” to CAR
question
– Describe dangers of riding with a person who has been
using alcohol/drugs
– Consider “Contract for Life”
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
CRAFFT screening tool, Children’s Hospital Boston, 2009.
Positive CRAFFT screen
• “Yes” to one question in part A
– Counsel patient on negative health effects of drug and
alcohol use.
– Try to identify a negative aspect of drug/alcohol use that
the patient has recognized independently.
– Agree to stop using drugs/alcohol.
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
Available at: http://www.mcpap.com/pdf/CRAFFT%20Screening%20Tool.pdf
Positive CRAFFT screen
• “Yes” to >2 questions
Positive CRAFFT screen
• “Yes” to >2 questions
– Assess type of drug(s) used, quantity and frequency
Positive CRAFFT screen
• “Yes” to >2 questions
– Assess type of drug(s) used, quantity and frequency
– Assess for substance use disorder diagnosis
DSM 5 criteria for substance use disorder
The new DSM describes a problematic pattern of use of an intoxicating substance leading to
clinically significant impairment or distress, as manifested by at least two of the following,
occurring within a 12-month period:
1. The substance is often taken in larger amounts or over a longer period than was intended.
2. There is a persistent desire or unsuccessful effort to cut down or control use of the substance.
3. A great deal of time is spent in activities necessary to obtain the substance, use the substance,
or recover from its effects.
4. Craving, or a strong desire or urge to use the substance.
5. Recurrent use of the substance resulting in a failure to fulfill major role obligations at work,
school, or home.
6. Continued use of the substance despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of its use.
7. Important social, occupational, or recreational activities are given up or reduced because of use
of the substance.
8. Recurrent use of the substance in situations in which it is physically hazardous.
9. Use of the substance is continued despite knowledge of having a persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated by the substance.
10. Tolerance, as defined by either of the following:
-A need for markedly increased amounts of the substance to achieve intoxication or desired
effect.
-A markedly diminished effect with continued use of the same amount of the substance.
11. Withdrawal, as manifested by either of the following:
-The characteristic withdrawal syndrome for that substance (as specified in the DSM- 5 for
each substance).
-The substance (or a closely related substance) is taken to relieve or avoid withdrawal
symptoms.
mild substance use disorder is suggested by the presence of 2-3 symptoms, moderate by 4-5
symptoms, and severe by 6 or more symptoms
Positive CRAFFT screen
• “Yes” to >2 questions
– Assess type of drug(s) used, quantity and frequency
– Assess for substance use disorder diagnosis
– Assess patient’s willingness and perceived barriers to
decreasing use
Positive CRAFFT screen
• Options for intervention:
– Develop a plan to decrease use and follow up in 1 month
within primary care to assess progress
– For more serious substance abuse conditions, refer for
specialty treatment
– For safety concerns, refer to the ED
Positive CRAFFT screen
Motivational interviewing
CRAFFT screen
Part A, response
Part B, response
Risk level
Intervention
“No” to all
questions
“No” to all
questions
Low
Praise good
choices.
“No” to all 3
questions
“Yes” to CAR
question
Elevated
Provide “Contract
for Life.”
“Yes” to 1 question
“No” to all
questions
Elevated
Recommend
abstinence.
“Yes” to >1
questions
“Yes” to >1
questions
High
Assess for
substance use
disorder,
motivational
interviewing, refer
for treatment.
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Department of Behavioral Health
Presentation Topic:
Substance Use and Co-Occurring Treatment and Services
Presentation Purpose:
Provide Pediatric Primary Care Physicians information regarding programs and resources for
youth with substance use issues in D.C.
Youth Treatment Coordinator
Nicole Martino, LICSW
April 10th, 2015
DC Department of Behavioral Health
Programs
Four ASTEP (Adolescent Substance Treatment
Expansion Program) Providers:
Hillcrest Children and Family Center
Latin American Youth Center
Riverside Treatment Center
Federal City Recovery
DC Department of Behavioral Health
Screening and Assessment
Family of GAIN Instruments: An evidence based tool
utilized to screen and assess for substance use and cooccurring mental health disorders
GAIN SS- Screening
GAIN I- Comprehensive Assessment
GAIN M-90- Follow up (assesses changes)
DC Department of Behavioral Health
Treatment
Adolescent Substance Use Treatment: All four ASTEP Providers
are able to provide outpatient and intensive outpatient
substance use treatment to include the following:
Group Therapy
Case Management
Clinical Care Coordination
Individual Therapy
DC Department of Behavioral Health
Treatment Continued…
Co-Occurring Treatment: All ASTEP Providers are trained to assess for cooccurring disorders utilizing the GAIN Tools
Three of the four ASTEP Providers are trained in the Evidence Based
Treatment Model: ACRA (Adolescent Community Reinforcement Approach)
Hillcrest Children and Family Center
Latin American Youth Center
Riverside Treatment Center
DC Department of Behavioral Health
Access to Services
• Adolescents and their families can access services by
contacting the Access Helpline for enrollment or by
contacting any of the four ASTEP Providers directly
to make an appointment.
DC Department of
Behavioral Health
Contacts
• Access Helpline: (888) 7WE-HELP/(888) 793-4357
• Four ASTEP Providers
Hillcrest Children and Family Center: (202) 232-6100
Latin American Youth Center: (202) 319-2265
Riverside Treatment Center: (202) 889-3182
Federal City Recovery: (202) 548-8460
• Department of Behavioral Health- Assessment and Referral
Center: (202) 727-8473
DC Department of Behavioral Health
Questions?
• Bhavin Dave, MD: [email protected]
• Katherine Hobbs Knutson, MD MPH:
[email protected]
• Nicole Martino, LICSW: [email protected]
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